(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
Air in the vitreous cavity is the weapon of choice to achieve retinal reattachment (F-A-X); the air is then kept in the eye to perform the laser treatment. Laser cerclage, even if the retina is attached, is easier to carry out in the air-filled eye (see Sect. 30.3.3). Air can also be used a short-term tamponade (see Sect. 35.1) and for various other purposes (see below, Sect. 31.3).
31.1 The Technique of F-A-X
Regardless of all other circumstances, two caveats are important to keep in mind:
Never use too high an air pressure.
The jetstream hitting the retina is one possible cause of a visual field defect.
Do not allow the infusion cannula to point toward the disc or macula.
31.1.1 Attached Retina
This is a rather straightforward procedure.
Keep the flute needle over the disc.1 Do not touch the disc, and hold your hand firmly.
Switch to air and aspirate the fluid as the air is coming in and pushes the BSS posteriorly.
If absolutely all of the BSS needs to be evacuated,2 patience is in order. It will take a couple of minutes for all the fluid to collect posteriorly.
Pearl
The intravitreal fluid adheres to the retina, however weakly: trickling down takes time. Think about your coffee mug after you drank all your coffee; within seconds, a small pool of coffee starts to become visible at the bottom of the mug.
31.1.2 Detached Retina (Retinal Reattachment via Draining Through a Retinal Break)3
This may be a rather frustrating maneuver for the inexperienced surgeon.
Mark the central edge of all retinal breaks4 so that they remain visible in an air-filled eye.
The retinal break, so conspicuous under fluid, is likely to “disappear” under air.
Turn the eye so that the central-most retinal break is at the deepest possible point of the eye.
Insert the flute needle. Position your hand firmly, holding securely the tip of the flute needle just above the break.
Lift your finger off the silicone chamber only when the flute needle’s tip is in position.
Occasionally, the subretinal fluid will drain even without employing air.
Switch to air. The air pushes the subretinal fluid posteriorly, toward the flute needle’s opening.
Unless the RD is old, the fluid is not viscous: the fluid column readily enters the flute needle as long as the column is not interrupted.
Q&A
Q
How do you drain a subretinal fluid that is very viscous?
A
Too viscous a fluid will either not enter the flute needle at all or it will rapidly obstruct it. (Naturally, the smaller the gauge, the greater the chance that this occurs.) The surgeon either asks the nurse to repeatedly flush the silicone chamber and the needle itself, or, preferably, choose active suction. The latter may be possible with the flute needle (see Fig. 36.2) or the probe. The port may need to be “dipped” into the subretinal space to avoid catching the retina (see Sect. 25.2.6).
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